A 43-year-old patient was found dead in her home hours after being inappropriately released from hospital, an investigation has found.

The woman, known as Ms B, had been discharged from the Royal Glamorgan Hospital in Llantrisant a day after being admitted suffering from hypothermia and having taken an overdose of methadone.

Ms B had earlier been reported missing and was found by police lying on the floor outdoors, smelling of alcohol. She had also been given the lowest score possible on the Glasgow Coma Scale, which indicates the severity of a coma.

After treatment a review was carried out by a consultant physician and a psychiatric nurse decided Ms B’s apparent self-harm risk was low, leading to her being discharged.

Missed opportunities 'alarming'

But she was discovered dead in her bedroom the following day at 8am – less than 24 hours later – having developed pneumonia.

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An investigation by the Public Services Ombudsman for Wales, which acted after a complaint from Ms B’s mother, Mrs A, says it is “alarming” that opportunities to spot her developing pneumonia were missed.

The ombudsman has said there had been a lack of clinical observations carried out – and whether or not she could breathe unassisted had not been checked.

If those things had been done, the ombudsman added, the development of the infection may have been noticed.

Cwm Taf University health board has apologised for the incident, which took place in April 2013.

Action plan to address failings

It has been ordered to pay a nominal £3,000 as a recognition of the distress caused by the possibility Ms B could have survived if there had not been those clinical failings.

The health board will also implement an “action plan” to address those failings.

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Mrs A had given evidence to the investigation in which she said her daughter “would still be alive” if the hospital had kept her in for further observations.

The report, published today, stated: “The ombudsman cannot establish, with any certainty, that the eventual outcome for Ms B would have been different as a result [of repeating clinical tests].

“However, he accepts, with considerable regret, that this is a possibility. He also recognises that the implications of this, for Mrs A and other members of Ms B’s immediate family, are immeasurable.”

Apology from health board

Chris Vinestock, the ombudsman’s director of investigations, said: “It is alarming that, as a result of poor discharge management, opportunities to identify Ms B’s developing pneumonia were missed. The implications of this for her family are immeasurable.

“Furthermore, the health board’s response to Mrs A’s concerns about her daughter’s care was inaccurate and misleading, claiming that there was no evidence of any infection despite blood tests clearly indicating this was a possibility.

“I urge the health board to learn from Ms B’s death and address each of the clinical failings identified in this report, not least the development of a discharge policy.

“By doing so I hope that patients will no longer be discharged from hospital until all reasonable steps have been taken to ensure they are fit to do so.”

Allison Williams, chief executive of Cwm Taf University health board, said: “We reiterate our deepest sympathy and sincere apologies to the family for the failings identified within the report.

“We accept the Public Services Ombudsman’s findings in respect of this case and work is ongoing within the health board to address the report’s recommendations.”